EEOC Employment Discrimination Complaint Form

EEOC Employment Discrimination Complaint Form

Complainant Name:   Complainant Address:

Respondent (Employer) Name:   Respondent Address:

RECITALS

WHEREAS, the Complainant asserts that on or about the Respondent engaged in employment practices that discriminate against the Complainant on the basis of one or more protected characteristics set forth below;

WHEREAS, the Complainant seeks an administrative investigation and resolution under applicable federal statutes prohibiting employment discrimination and any remedies available pursuant to such statutes, including but not limited to equitable relief, back pay, reinstatement, and compensatory damages;

WHEREAS, the parties desire to document the allegations and pertinent facts necessary to initiate an administrative charge and to provide the Respondent notice and opportunity to respond to the allegations;

NOW, THEREFORE, the Complainant submits this Complaint and alleges as follows.

1. JURISDICTION

This administrative complaint is filed under statutes prohibiting employment discrimination. The Complainant alleges that the Respondent is an employer as defined by applicable law and that the acts alleged occurred within the time period and within the jurisdictional scope for administrative review. The Complainant requests that the agency accept and investigate the charge and determine whether unlawful employment practices have occurred.

2. PARTIES

Complainant is: . Respondent is: with approximately employees.

3. ALLEGATIONS

3.1 Nature of adverse action(s): The Complainant alleges the Respondent engaged in the following adverse employment actions (select all that apply and describe):

Termination    Failure to hire    Denial of promotion    Pay reduction/demotion    Harassment/hostile work environment    Retaliation   

3.2 Date(s) of alleged discriminatory acts: from to . If continuing, state facts showing ongoing nature.

4. BASIS OF DISCRIMINATION

The Complainant asserts that the adverse actions were based on the following protected characteristic(s). Check all that apply:

Race    Color    Religion    Sex (including pregnancy, sexual orientation, gender identity)    National origin    Age (40 or over)    Disability    Genetic information    Retaliation for protected activity

5. RELIEF REQUESTED

The Complainant requests that the agency investigate the allegations and seek appropriate relief including, as applicable, injunctive relief, reinstatement or hiring, back pay, front pay, compensatory damages, punitive damages where authorized by law, and any other relief deemed just and proper.

6. INVESTIGATION COOPERATION

The Complainant agrees to cooperate in any investigation, including providing documents, appearing for interviews, and authorizing release of employment records where necessary. The Complainant understands that false statements or material omissions may subject the Complainant to penalties under law.

7. CERTIFICATION

I certify under penalty of law that the information contained in this complaint is true and correct to the best of my knowledge and belief. I understand that filing a false complaint may subject me to legal penalties and that this complaint authorizes the agency to investigate the allegations herein.

8. NOTICES

Notices and communications concerning this complaint shall be delivered to the addresses set forth above. The Complainant and Respondent shall update contact information promptly in writing if a change occurs during the pendency of any administrative proceedings.

9. AMENDMENTS AND WAIVER

This Complaint may be amended to add facts or claims discovered during the administrative process. No waiver or modification of any provision of this Complaint shall be effective unless made in writing and signed by the party to be charged.

10. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Complaint shall be governed by applicable federal statutes and regulations prohibiting employment discrimination and by the administrative rules governing enforcement. This document constitutes the entire statement of the Complainant's claims submitted at this time and supersedes any prior oral or written statements to the extent inconsistent. If any provision of this Complaint is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

11. COUNTERPARTS

This Complaint may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument.

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